The real problem with Canadian health care

Dr. Jeffrey Turnbull glances at the top line of the patient’s chart. He blocks with his hand the subsequent lines that describe the patient’s condition and treatment since being admitted the night before. “I know the rest,” Turnbull predicts.

The patient, R, is a 94-year-old male. Turnbull’s quick assessment: “This will cost about $50,000 for the 20 to 30 days he is here.” Turnbull reads the rest of the chart. R came from a retirement home. He was given a battery of tests after being admitted to the Ottawa Hospital. The chart, all handwritten by nurses and residents, shows R’s vital signs are acceptable, but he has a urinary-tract infection, lesions (likely malignant) on his back and a form of dementia.

“That man should never have come into an acute-care hospital,” Turnbull observes. “Someone should have made arrangements a month ago for him to go somewhere, but now it’s happened.” Turnbull continues: “There are maybe 160 people in the hospital at $1,100 a day waiting for long-term care. So we’re spending maybe $180,000 a day for care that is crappy, not in their best interests. In a nursing home, it would be about $200 a day. The care itself here isn’t crappy, but this man won’t have rehab. He’s not going to have his family around.

“They’ve done 10 tests so far. What will happen now is that we will treat his urinary-tract infection. We’ll stabilize his condition. We’ll call the family and we’ll agree that he should be sent to a long-term care facility, and then he’ll wait for a bed. We’ll transfer him to our waiting unit, and then he’ll wait.”

Turnbull’s Monday-morning prediction introduced me, in the fall of 2011, to a week learning what goes on in the Ottawa Hospital, one of the largest teaching hospitals in Canada, with an annual budget of about $1-billion and a template for similar institutions across Canada. The week allowed me to watch one part of Canadian health care across wards, operating rooms, the emergency department, administrative offices, inner-city outpatient care. It became evident throughout the week that at the Ottawa Hospital, as at other large acute-care hospitals across Canada, brilliant medicine is practised, caring staff offer succor and support, technologies and drugs unheard of several decades ago help patients with their ailments. Some of the very best features of the Canadian health- care system were on display; so were some of the worst.

A hospital is a complicated institution, and a teaching hospital the most complicated health-care institution of all. It is the apex of Canadian health care, a source of immense community pride, a magnet for medical talent, an institution to which Canadians head for all sorts of health problems. The Canadian health-care system was originally designed around hospitals and, to a fault, it remains so today — a system whose hospitals struggle to cope with changing patient demand, an aging population (R, for example), higher costs, global budgets imposed by provincial capitals, fast-developing technologies, rigid rules, new drugs and the social inequities that lead to poor health.

Turnbull, an internal-medicine specialist, is the Ottawa Hospital’s chief of staff. When I spent time with him, he had just completed a year (2010-2011) as president of the Canadian Medical Association, during which the CMA mobilized a public campaign to draw attention to the health-care system’s challenges. Turnbull believes fiercely in the public health-care system and brought immense passion to his one-year post

Turnbull did not spend his presidency pleading for more money for physicians or echoing publicly their various complaints, let alone preaching for private health care. He understood that the profession had recently done so well financially that it would have been indecent of physicians to complain. Instead, he asked his profession, and the Canadian public, to debate a CMA document that he helped to craft, Health Care Transformation in Canada.

“The founding principles of Medicare are not being met today either in letter or in spirit,” it charged. “Canadians are not receiving the value they deserve from the health care system … Canada cannot continue on this path … Nothing less than one of Canada’s most cherished national institutions is at stake. Unwillingness to confront the challenges is not an option.” Of all recent reports on Canadian health care, his diagnosis — from a passionate believer in medicare — was among the starkest.

Turnbull is back full-time in the hospital now, although he remains in demand as a speaker, a doctor engagé. He breaks away each year to work in Bangladesh and Africa at clinics he helps to finance. He is what every patient would wish his or her doctor to be: smart, caring and personable. Having analyzed the health-care system’s weaknesses, he broke the taboos too many other defenders of Canadian medicare try to impose on debate. His bottom line: medicare, as now structured, financed and administered, is not good enough.

Turnbull continues his Monday-morning rounds, a preliminary review of about two dozen patients. His survey completed, he joins residents, other doctors, medical students, a pharmacist and an assignment nurse around a table in a nondescript conference room. This daily meeting allows everyone to review the roster of patients: their treatment and needs and conditions, how long they should remain on the ward, where they might go thereafter.

New patients arrive every night, if there is room for them. Other patients leave during the day, sometimes to be discharged from the hospital, often transferred to a ward in the hospital called the APU, the Awaiting Placement Unit, where they will wait, and wait, and wait some more for a more appropriate and cheaper place outside the hospital. Patient A arrived overnight, and so shows up as a new patient on the chart along with 94-year-old R.

Patient A had become involved in an altercation in a parking lot. He claimed that a driver had run over his foot with a car and his finger got jammed in the door in the ensuing dispute. Crying, fearful of losing his foot, afflicted by a history of drinking, he was demanding that fluid be drained from his foot. He was giving the nurses a hard time, a medical student reported.

Another patient, S, “presented” (the verb used in hospital circles) with multiple problems: Crohn’s disease, a form of dementia, blindness, shaking all over, an alcoholic. Later that day, Turnbull gently approaches S on the ward and asks how much alcohol she consumes a day. “About 13 ounces,” she replies. Her pallor is grey, and she is still shaking. Who buys the alcohol? Turnbull asks the blind woman. Her husband. If she returns home, Turnbull continues, will she stop drinking? Yes, she would like that, S answers.

Turnbull turns away. If Patient S did go home, he observes, her husband would still be there, so she would resume her habit. She should go into some form of long-term care facility, except that she would have to agree, and no places are available anyway. We will stabilize her condition. She will return home. She will be back, he predicts.

At the morning meeting, most of the patients under discussion are elderly. Excessive alcohol consumption played a role in perhaps a quarter of the cases. Two had fallen in their homes, several had forms of dementia, most had multiple problems, often chronic. These patients would likely remain for a while in internal medicine wards. They form an indicative but not necessarily representative profile of hospital patients. A patient list in orthopedics, cardiology, endocrinology or oncology would be different, although they too would all be tilted toward an older clientele. Some medical disciplines get people in and out of hospitals fast, especially after routine surgeries and after childbirth without complications. Internal medicine must deal with the impact of aging as forcefully as any specialty. Whether seniors should be treated in a hospital, and whether they should remain on wards such as internal medicine as long as they do, is another matter.

It also became clear at the morning meetings throughout the week that medical personnel spend as much time discussing patients’ social and economic conditions as their physical health needs. What often brought patients to the internal medicine ward were the results of their unsatisfactory social and economic conditions. Most of them were old and often frail. They frequently did not have much money, lived in precarious family arrangements (if there was a family at all) and had presented to hospitals before. Sending them home, even if they were technically well enough, did not seem like the best option because of familial or housing conditions. Discussions among medical staff around the table often sounded much like a session among social workers.

Orders were given for a few patients who needed to go elsewhere that day or soon. Where to go? Inside the conference room, the case of a 71-year-old man with type 2 diabetes, hypertension and other ailments had been discussed. Outside the room, Turnbull commented, “He should have gone straight to a long-term care facility or, better still, a long-term care facility attached to a nursing home with family doctors involved. Chronic disease management, which is now 57% of the action, should be built around things outside the hospital, but the acute-care system is being used for that purpose. This man should never have come into an acute-care hospital.”

R’s case comes up. “What will happen now is that we will treat his urinary infection,” Turnbull says after the discussion. “He’s horribly demented. We’ll call in the family. We’ll say that he is best cared for in another environment. Then we’ll agree that he should go to a long-term care environment. Then he’ll wait for a bed. We’ll transfer him from here to our waiting place and he’ll wait. They want to do some tests on the cancerous lesions on his back. I’ll try to put an end to that.” The lesions will not kill him before other frailties.

The Ottawa Hospital produces a patient flow monitor (PFM) document throughout the day. It identifies how many patients are in the hospital, overnight admittances, patients waiting for assignment, critical-care occupancy and the number of ALCs, or alternative level of care patients. In a properly organized health-care system, these ALC patients should not remain in hospital for more than a few days. They should go as quickly as possible to nursing homes, long-term care facilities or a supervised home-care program.

Turnbull asks for the PFM at noon. It shows 1022 patients in the hospital’s two main campuses, the Civic and the General, and 135 ALCs. Thirteen percent of the beds, therefore, are occupied by people who, under ideal circumstances, should not be in the hospital.